Are Clinicians too Quick to Diagnose Bipolar Illness in Children?

Treatment for the extreme emotional outbursts seen in some children may benefit more from family therapy than from psychopharmacology.

The statistical rise in diagnoses of pediatric bipolar disorder over the last several years has stirred debate among child psychiatrists, and there's no lack of argument about its implications, said Allan Josephson, M.D.

“Office-based visits with a diagnosis of bipolar disorder for youth have risen 40 times in 10 years, from 25 per 100,000 in 1994-95 to 1,003 per 100,000 in 2002-03,” he said at the annual meeting of the American Academy of Child and Adolescent Psychiatry in New York in October.

There are good and bad outcomes of this development, said Josephson, a professor and vice chair for child and adolescent psychiatry services and CEO of the Bingham Child Guidance Center at the University of Louisville.

Bipolar disorder does exist in children and adolescents and may well have been underdiagnosed in the past, so the increased attention to the disorder has brought needed treatment to children.

However, some irritable, explosive children are lumped into the bipolar category, possibly because no other label seems to fit, said discussant Gabrielle Carlson, M.D., a professor of psychiatry and pediatrics and director of child and adolescent psychiatry at Stony Brook University School of Medicine in New York.

Other researchers have proposed a diagnosis of “severe mood dysregulation” for these children, who are characterized by chronic irritability, hyperarousal, and hyper-reactivity, but not the episodic manic symptoms typical of DSM-IV bipolar illness.

“The emphasis on bipolar disorder as an explanation [for this behavior] has also communicated the unhealthy idea that children's behavioral problems lie outside the child's or the family's control,” said Josephson. “It changed the point of control from the child to ‘chemicals.’ That leads to misguided therapies, focusing on disease elements to the neglect of psychosocial aspects of development.”

A number of changes within the profession of child psychiatry also have contributed to the confusion over diagnosis and nomenclature, he said.

These include having less time available for clinical work and for collecting developmental and family histories. There is a narrowing emphasis on neuroscience today, along with insufficient integration between the biological and psychological sides of psychiatry.

In her discussion, Carlson reported that she sees children with what she called “difficult temperaments.” They have rages and meltdowns, adapt poorly to change, and have trouble transitioning. They exhibit poor sleep patterns, poor planning and working-memory abilities, and a need for immediate gratification.

Like children with pervasive developmental disorders, they misread social cues and can't put their frustrations into words.